Thank you and good morning. So just so I can provide some context, Cooper is a hospital in Camden, New Jersey on the corner of MLK Boulevard. It's not, it's resource-poor institution. We have, we cover 10 ICUs across seven hospitals. We have 30 attending faculty, 10 APPs, and we teach 32 fellows at any given time. Just in the context of who we are. I have no disclosures and I, you know, my topic today is to talk about CCO in the midst of a crisis. So as, what I'll talk about today as attending or as intensivists or people practice critical care, crisis is part of our career. It is part of our DNA and we will always be involved in them in one way or another. The question is the size of the crisis. In the midst of a crisis, how do you deal with it? What's the best way organizationally to handle a crisis? Is it the classical model of reporting to a department head or a model of a critical care organization where you report directly to the hospital administration and you have more autonomy? And is there any data behind either approach? For me, the defining moment of my career was in 2010. I went to Haiti as part of a civilian response. 200,000 people died there. It was the first outbreak of cholera in the Western Hemisphere in a hundred years. And when I was there, I saw although we had equipment and resources, we weren't really able to help people as effectively as we would have liked. You can see from the timeline over to the side there. I know I'm getting old, I can't really see myself, so I apologize. But time on the right, you can see that we've been involved in pandemics and endemics for over a hundred years, leading up to obviously the COVID-19 pandemic that we're currently in. We know any anywhere between 12 and 56 thousand people die a year from influenza. And that, you know, depending on where you are, your ICU could be overrun by influenza on any given year. So to credit to the critical care, to intensivists and people who practice critical care across the world, over a period of about eight years, there was guidelines that were produced. This first guideline is very, very insightful. It basically says, and you know the takeaway point from it from Rubenson and the people who did put it together, is that we actually have the technology and we have the resources. We're not organized enough to deal with a mass influx of patients. And they were talking about that in 2008. Sprung, who practices in Israel and has unfortunately too much experience with crises, put together triage guidelines a couple years later. If you have too many patients who should be able to get inside an intensive care unit in the midst of a crisis, and some things you can reference to. And I can acknowledge during the COVID-19 pandemic, in the early days, that our critical care organization referred to these guidelines. This is a much larger set of documents, but basically, and I would suggest people look at it if they have the opportunity, written by many of the experts in critical care. But in amongst mass casualty or mass influx of patients, how do you deal with them? How do you change staffing? How do you respond in the heat of the moment? So that puts us in this moment. We know in March of 2020, all of us watched in horror as our colleagues in northern Italy and the Lombardy region were overwhelmed. They had the double, double the number of ICU patients as they had ICU beds. Almost a hundred percent of the patients were ventilated. It led to increased morbidity and mortality in scenes that I think many of us will never forget. The British and the National Health System responded appropriately. They altered their nursing staffing ratios for the critically ill, and they basically, by referring to the guidelines that existed previously, and responded nimbly. And then none of us will ever forget the scenes out in New York and our colleagues, what they suffered in March of 2020, and how the city suffered when the National Guard had to step in to help. And many of our colleagues, some of our fellows, had to go serve to help. So the question is, how do you avoid chaos? This slide will haunt me for the rest of my life. My family's from India. In 21, the country was overwhelmed by COVID-19, and this is a picture of a mass crematorium of, because so many people were lost in the country, actually stopped officially counting COVID deaths somewhere during the crisis. The question is, during a critical, during a crisis, can a critical care organization respond more nimbly and more effectively than the classical model? So we know critical care organization is a common organizational structure that's focused on throughput, quality, standardization, and reports directly to hospital administration, or if they do report to possibly a department head, they have a direct line of communication over the site, lines of site, over all critical care practice in their institution. You can see the differences between a critical care organization, and we'll refer to the independent model or the classical model, and this has been talked about in the previous two talks, so I won't belabor the point, but just imagine, and I guess no one here really has to imagine it, but maybe trainees are starting now, if you're in the midst, at the heat of the battle, right, and you have too many COVID patients, and there's a disagreement about which patient should be admitted into your intensive care units, because they're not under the leadership of one group or one organization, how disruptive that can be, or protocols aren't standardized, and people want to go rogue and, you know, start using medications that aren't necessarily indicated, or don't have proof or benefit behind them without having a discussion, and these types of things played out on the front page of the New York Times, faculty meetings, we were reading about them, and then bed allocation, that you have a critical care organization, you have a centralized group that talks about who needs to go in what beds, how does that happen, how do you introduce new technology in the midst of a crisis, so what are critical care organizations, what are intensive care units, what are intensivists, are people who practice critical care obsessed with, space, right, who gets into the bed when, never did, I think, on the front page of major newspapers, we would be looking at ICU capacities, stuff, like do you have the supplies you need to be able to do the work you need, the staff, right, the great resignation, and the logistics of basically being able to provide care, support your staff in the midst of a crisis, so we'll go through it a little bit here, I obviously want to applaud the Sinai group here, they're not the only people who responded novelty to, with novelty to a crisis, but they did publish it, and as a critical care organization, they need to be commended for perhaps providing the way for future generations to how to respond to a crisis, well you can see here in this graph, in March of 2020, or the spring of 2020, when they were overwhelmed with patients, a deluge of patients for COVID-19, they doubled their ICU capacity, and they doubled the number of their ICU beds, because of having centralized leadership, they've made this possible, at least that's how the paper reads, and that's how they tell the story, so I believe it, and it was absolutely amazing, what they used was the SECM model to say that intensives would be the people most capable to care for patients, then after the anesthesiologists, and APPs, and non-critical care providing staff, they used novel staffing methods with teams, so you'd have teams where you'd have a critical care attending, you have a critical care fellow, you'd have non-critical care providers working together, and I can acknowledge in our critical care organization, we did the exact same things, we opened up new intensive care units, and those new intensive care units, we would have anesthesiologist staff half the unit, we'd have intensive staff for the other half of the unit, the critical care fellow would go to the anesthesiologist, and the anesthesia residents would come with the critical care attending, so staffing, and we're talking about it, you know, how do you augment staffing, because there are only so many bodies, can you rapidly take care of more patients with not having more people to do it, so telemedicine played a huge role in this, and it plays a huge role in the COVID-19 crisis, but also just in any sort of crises, and what you can see here is on the right, this came out of an article that talked about UPMC and Mayo Clinic that helped New York-Presbyterian see critically ill COVID patients in the height of the crisis in 2020, and rounded on patients twice a day, to the left is a generic picture of a prone patient, the reason that resonates with us is that our critical care organization stood up a tele-ICU model for a community hospital on the Jersey Shore, and we were able to keep significantly sicker patients there than we ever were before because of the telemedicine presence we created on the fly. So, you know, obviously this probably brings back trauma to many people here, but in March of 2020, we also didn't have enough supplies, and, you know, the national stockpile didn't have the supplies that we needed, our colleagues in New York were overwhelmed, in Jersey we're close behind, I obviously want to compliment my hospital and hospital leadership for securing the supplies that we needed. I will just say, as a leader of a critical care organization, it was much easier for me to be able to speak to my hospital CEO, who I had an audience with because of the way our organization is run, than having to go through a department chair, whether into whatever type of department chair it may be, not because they don't care, not because they won't advocate, but because of having that direct line of communication established prior to a crisis is very, very helpful, and we had the resources we needed, albeit bought in unusual ways, and changing different colors and different sizes, but we had what we needed, I'm grateful for that. And then the structure, I think that this is super important, right? So if you think about a critical care organization, and the references are here for those who are interested in these slides, but if you think about the structure of an organization, if you have an organization that exists prior to a crisis, you can rely on this structure. There was a survey of critical care organizations done that showed that 80% of critical care organizations felt like they had a structured triage process to take care of the critically ill. How important was that in the midst of the crisis, right? That you could keep less critically ill patients at smaller community sites, and you could bring the patients who needed tertiary care over to your institution. For us, it was that they came over because they needed ECMO, and we were basically responding for, New Jersey was divided into three, we were the lead hospital for Southern New Jersey, but we provided support all the way up to Northern New Jersey. But the defragmentation of care, so you can see these are four pillars, but if you are thinking about quality finances and triage and those types of protocols and standardization prior to a crisis, you're much more able to deal with it during a crisis. Not that non-critical care organizations don't think about this, but if these are the governing pillars and your institution knows that's the way you're going to function, we'll be able to rely on you more effectively in the midst of a disaster. For us, it also allowed us to think outside the box. It was abundantly clear in the spring of 2020 that we have three cardiac surgeons, two thoracic surgeons, that they didn't want to be going into the rooms cannulating patients for ECMO. And while our group was willing to do it and recognize we had to be in the rooms one way or another, and it allowed me to have conversations with the hospital CEO and the leadership around the hospital as the head of critical care organization saying, on the fly, we need to change our cannulation process. We also need to change our ability to care for how many mechanical circulatory support patients we have. So, you know, at that point we could care for six patients and we were able to increase our capacity to be able to care for 12 patients at a time. This is an important piece of literature. It's the 2022 evaluation of burnout amongst critical care providers. We can see here, and this is I think is great news, that 60-70% of people derive tremendous satisfaction at work, which is the good news. The bad news is on the other end of the graph is that a lot of people had a feeling of depersonalization and lack of connection with their colleagues. Critical care organizations, I mean this is literature that just supports them, talk about the leaders say that they feel more empowered and that they feel that they're supported to be able to perform their mission to support and care for the critically ill and also support their staff. I will acknowledge that amongst our 30 faculty that I'm able to have a personal relationship with all of them and if the things that they need they can come to me. We consistently have the highest satisfaction scores in our hospital through three years of a pandemic. I think this is a witness, this is one of our intensivists on the left, Dr. Adam Green, and next to him is a nurse who's also a COVID survivor, Mr. John Rosen. I've been trying to get my hospital make a billboard out of this. It was expired when I go up to New York and see the Montefiore billboards of all the people they save. The point about this is that my faculty from the bedside to outpatient are connected with people and I think that's helped us to stay more engaged. You'd say well what does that have to do with the critical care organizations? They feel like they had the latitude to do what they need to do and I'm able to support them in a way that I think that when you're under division or department you're not able to. This is a fantastic document that talks about how do you respond in the midst of a crisis. I don't expect anyone to be able to read it but number seven is we suggest the early transfer of patients before a hospital is overwhelmed and that promotes the effective conservation of resource and less deviation of routine care standards. So that's part of the basis of a critical care organization. Like I said we are covering you know ten intensive care units, seven hospitals across southern New Jersey, some of my faculty sometimes have to drive an hour to work. We every day think about who comes to our intensive care units to our tertiary care, how we're able to do that and so in the midst of a crisis it was just natural and we were able to go forward. So maybe number 11 on this will be possibly an inflammation of critical care organization to do to be a better effective deal with crises. So in conclusion crisis is inevitable but is chaos preventable? Space, staff, supply, structure, logistics will always matter. CCOs think about them every day so in the midst of a crisis a CCO will better be able to respond and data exists about CCOs something to consider for your own organization. Thank you very much for your time.

critical care organization

crisis management

preparedness

centralized leadership

triage processes